L10: Abdominal Exam

Question 1

Abdominal Landmarks

Answer 1

Question 2

What are the abdominal quadrants?

What are the abdominal sections?

Answer 2

• Quadrants
  
  • Right Upper Quadrant (RUQ)
  • Left Upper Quadrant (LUQ)
  • Right Lower Quadrant (RLQ)
  • Left Lower Quadrant (LLQ)
• Sections
  
  • Epigastric
  • Umbilica
  • Hypograstric or Suprapubic

Question 3

Abdominal Quadrants

Answer 3

Question 4

What sequence do you perform the following elements in?

Auscultation, Inspection, Palpation, Percussion

Answer 4

1. Inspection
2. Auscultation
3. Percussion
4. Palpation

Question 5

Abdominal Exam: Inspection

What are you inspecting for?

Answer 5

• General appearance of the patient
• Contour/Shape/Symmetry
• Distention
• Hernias/Bulges/Masses
• Peristalsis/Pulsations
• Skin markings

Question 6

Inspection: Contour/Shape

Define:

Flat

Rounded

Scaphoid

Protuberant

Answer 6

Question 7

Protuberant Abdomens

What can cause protruberant abdomens?

Answer 7

Question 8

Umbilical Hernia

What is it?

Answer 8

Herniation of abdominal contents through a defective umbilical ring

Question 9

Incisional Hernia

What is it?

Answer 9

Herniation of abdominal contents through a previous incision site

Question 10

Diastasis Recti

What is it?

How to test/observe?

Answer 10

Benign, separation of the rectus abdominis muscles

Abdominal contents form midline ridge

Obvious with flexion of neck “lift your head up”

Question 11

Ventral Wall Hernias

When to check for ventral wall hernias?

Technique?

Answer 11

• If you suspect but do not see an umbilical or incisional hernia
• Techniques:
  
  • Ask patient to raise head and shoulders off the table
  • Ask patient to raise both legs off the table
  • Ask patient to perform Valsalva maneuver
• Bulge of hernia will usually appear with this action

Question 12

Peristalsis & Pulsations

What are they?

Indication if observed?

Answer 12

• Peristalsis (visible waves of movement seen beneath the skin)
  
  • Can be seen in very thin people
  • Increased peristaltic waves of intestinal obstruction
• Pulsations
  
  • Normal aortic pulsation is frequently visible in epigastrium
  • Look for increased pulsation of abdominal aortic aneurysm

Question 13

Skin Markings: Ecchymosis

What is it?

Answer 13

Ecchymosis: a discoloration of the skin resulting from bleeding underneath, typically caused by bruising

Can be seen in intraperitoneal or retroperitoneal hemorrhage

Question 14

Skin Markings: Striae

Answer 14

Pink-purple striae of Cushings

Question 15

Skin Markings: Dilated Veins

Answer 15

• Abdominal wall veins normally scarcely visible
• Prominent veins most commonly suggest portal hypertension from cirrhosis
  
  • Portal hypertension promotes collateral venous circulation radiating from the umbilicus to the abdominal wall (Caput medusa)

Question 16

Auscultation

Purpose of auscultation

Why is auscultation performed second?

Answer 16

• Purpose:
  
  • Assess bowel sounds noting frequency and character
  • Assess for bruits (atherosclerotic disease)
• *Second phase of abdominal exam
  
  • Done before percussion or palpation to evaluate the activity of the intestines before altering bowel sounds with abdominal wall pressure

Question 17

Bowel Sounds

• Where do you auscultate for bowel sound?
• What is the frequency of bowel sounds?
• Character of bowel sounds:
  
  • What is normal?
  • What is abnormal?

Answer 17

• Generally completed in all four quadrants
• Frequency: 5-34 per minute
• Character:
  
  • Active/Normal
    
    • Clicks and gurgles
    • Prolonged gurgles of hyperperistalsis, the familiar “stomach growling” referred to as borborygmi
  • Altered/Abnormal
    
    • High-pitched tinkling
    • Hyperactive
    • Hypoactive

Question 18

Bowel Sounds: High-pitched, tinkling bowel sounds

What are they an indication of?

Answer 18

Intestinal Obstruction (early): Normal flow of intestinal contents is interrupted. Intestinal fluid and air under tension in a dilated bowel. Multiple etiologies.

Question 19

Bowel Sounds: Hyperactive bowel sounds

Cause?

Answer 19

• Diarrhea (gastroenteritis)
• Peritonitis (early)

Question 20

Bowel Sounds: Hypoactive bowel sounds

How to assess?

Indication?

Answer 20

• Is it quiet, or is it silent?
• Listen for several minutes
• Ileus – little to no bowel activity (absent)
• Peritonitis – may be hyperactive initially, but eventually becomes hypoactive due to progressively severe inflammation, may progress to an ileus

Question 21

Bruits

Where do you auscultate for bruits?

Answer 21

• Aorta
• Renal arteries
• Iliac arteries
• Femoral arteries

Question 22

Percussion

Purpose?

Where do you percuss?

What is normal?

Answer 22

• Purpose: Assess distribution of tympany and dullness
• Done in a minimum of four quadrants
• Normal: Tympany throughout with scattered areas of dullness representing fluid/feces, dullness of liver and spleen
  
  • Tympany – predominates because of gas in GI tract
  • Dullness – assess for organ enlargement (hepatomegaly, splenomegaly)

Question 23

Abnormal Percussion

What sounds would you hear? Indication?

Distended abdomen

Protuberrant abdomen

Answer 23

• Distended abdomen that is tympanic throughout suggests intestinal obstruction or paralytic ileus
• Protuberant abdomen with bulging flanks and dullness should prompt evaluation for ascites (fluid in peritoneal cavity)
  
  • Free fluid sinks to the dependent part of the abdominal cavity whereas gas-filled loops of bowel float to the top

Question 24

Liver Size

How to measure?

Normal size?

Answer 24

• Lower Liver Border
  
  • Begin in an area of tympany and percuss upward toward the liver
  • Note where dullness begins (represents lower liver border)
  • Mark with pen
• Upper Liver Border
  
  • Begin in an area of lung resonance and percuss downward toward the liver
  • Note where dullness begins (represents upper liver border)
  • Mark with pen
• *Measure the vertical span of the liver in the midclavicular line (MCL), normal size is ~ 6-12 cm in MCL

Question 25

**Hepatomegaly** What is it? Etiologies?

Answer 25

* **Hepatomegaly** – liver enlargement * Etiologies: * Cirrhosis * Hepatitis * Alcoholic liver disease * Abscess * Hepatic Tumor or Cysts * Hereditary conditions * Biliary/Cholestatic disease * Heart failure

Question 26

**Spleen** When spleen enlarges, which direction(s) does it expand? How to percuss? What are you percussing for?

Answer 26

* When spleen enlarges, it expands anteriorly, downward, and medially * Percuss the left lower anterior chest wall from border of cardiac dullness, at the 6th rib, to the anterior axillary down to costal margin and note distribution of tympany to dullness

Question 27

**Bladder** Is the bladder palpable? What are you percussing for? Abnormalities: cause of tenderness or distention

Answer 27

* Usually **non-palpable** * Percuss for tenderness and fullness in the suprapubic area * Bladder volume must be \> 400-600 mL before dullness appears * Abnormalities * Tenderness with *cystitis* * Distention from *urethral stricture, prostatic hyperplasia, neurogenic bladder, etc.*

Question 28

**Palpation** Purpose Technique

Answer 28

* _Purpose:_ * Assess for **areas of tenderness**, **muscular resistance**, **superficial masses and organs** (liver, spleen, kidneys), size of aorta * _Technique:_ * Patient should have **knees flexed** and arms at sides * Palpate **lightly then deeply** * Minimum of four quadrants, epigastrium, periumbilicus, and suprapubic

Question 29

**Light vs. Deep Palpation**

Answer 29

* **Light Palpation** * Elicits abdominal tenderness * Assess for muscular resistance (guarding and rigidity) * Identifies superficial masses and organs * **Deep Palpation** * Delineates pain * Identifies masses and organs * Note their location, size, shape, consistency, tenderness, pulsations, mobility * Palpate liver and spleen through **respiratory cycle** * Inspiration moves liver and spleen inferiorly **“take a deep breath”** * Expiration moves organs back into normal position

Question 30

**Muscular Resistance****:** _Guarding vs. Rigidity_

Answer 30

* **_Guarding (tensing)_** * **Voluntary** contraction of the abdominal wall muscles with palpation * May diminish when patient is distracted * **_Rigidity (stiffness)_** * **Involuntary** reflex contraction of the abdominal wall muscles * Persists over several examinations

Question 31

**Deep Palpation: _Abdominal masses_** _Examples of:_ Physiologic Inflammatory Vascular Neoplastic Obstructive

Answer 31

* Physiologic (*pregnant uterus*) * Inflammatory (*Diverticulitis*) * Vascular (*Abdominal Aortic Aneurysm*) * Neoplastic (*Colon cancer*) * Obstructive (*distended bladder or dilated loop of bowel*)

Question 32

**Typical Sites Abdominal Pain** _Origin of pain cuased in:_ RUQ or epigastric pain Suprapubic or sacral pain Epigastric pain Periumbilical pain Hypogastric pain

Answer 32

RUQ or epigastric pain → *from biliary tree and liver* Suprapubic or sacral pain → *from the rectum* Epigastric pain → *from the stomach, duodenum, pancreas* Periumbilical pain → *from the small intestines, appendix, proximal colon* Hypogastric pain → *from the bladder, colon, uterus*

Question 33

**Referred Pain** Where does pain in the following areas originate from?

Answer 33

Question 34

**Acute Cholecystitis** What is it? Location of pain? Radiates to... Positive test?

Answer 34

* Inflammation of the gallbladder * **RUQ pain** may radiate to right scapular area * **+ Murphy sign** (specialized exam)

Question 35

**Acute Pancreatitis** What is it? Location of pain? Radiates to?

Answer 35

* Acute inflammation of the pancreas * **Epigastric pain** may radiate to back

Question 36

**Acute Appendicitis** What is it? Location of pain? Radiates to?

Answer 36

* Acute inflammation of the appendix * Pain classically begins near the umbilicus then migrates to RLQ * McBurney’s point * **+ Psoas, Obturator, Rovsing Sign** (specialized exams)

Question 37

**Acute Diverticulitis** What is it? Location of pain?

Answer 37

* Acute inflammation of a colonic diverticulum (sac like mucosal outpouching) * **LLQ pain**

Question 38

**Renal & Ureteral Pain:** * Acute Pyelonephritis * What is it? * Specialized exam? * Nephrolithiasis * What is it? * Location of pain? Radiates to?

Answer 38

* ***Acute Pyelonephritis*** * Infectious inflammatory process involving the kidney * **+ Costovertebral angle (CVA) tenderness** (specialized exam) * ***Nephrolithiasis*** * Stones that may lodge throughout the urinary tract * Acute, severe, colicky flank pain that radiates down to the groin

Question 39

**Liver Palpation** Technique What should a normal liver feel like? Abnormal liver?

Answer 39

* Place your left hand behind the patient * Place your right hand in RUQ (fingertips below the lower border of liver dullness and pointed toward costal margin) * Have patient take a deep breath and feel for liver edge as it slides down to meet your fingertips * _Normal liver edge:_ * Soft, sharp, and regular with smooth surface * _Abnormal liver:_ * Firmness or hardness of liver, bluntness or rounding of its edge, and surface irregularity are suspicious for liver disease

Question 40

**Spleen Palpation** Technique Etiology of splenomegaly

Answer 40

* Place your left hand behind the patient * Place your right hand in LUQ, (fingertips below the left costal margin and pointed towards lateral chest) * Have patient **take a deep breath** and feel for the tip or edge of the spleen as it slides down to meet your fingertips * **\*Palpation must occur with deep inspiration** * **Splenomegaly Etiology** * Congestive diseases (cirrhosis with portal hypertension, heart failure, splenic vein thrombosis) * Hematologic malignancies * Viral (mononucleosis), bacterial, parasitic infections

Question 41

**Kidney Palpation** Technique Etiologies of kidney enlargement

Answer 41

* _Left Kidney_ * With your left hand, reach over and around the patient to lift up beneath the left kidney and with your right hand feel deep in the LUQ * Attempt to capture the kidney * _Right Kidney_ * With your left hand, lift up from the back and with your right hand feel deep in the RUQ * Attempt to capture the kidney * _Kidney englargement: etiologies_ * Hydronephrosis * Cysts/Tumors * Polycystic Kidney Disease

Question 42

**Aorta Palpation** What are you palpating for? Technique? Abdominal Aortic Aneurysm (AAA): define?

Answer 42

* Palpate for aortic size and pulsations * Proximal to the umbilicus to the left of the midline, apply steady downward pressure with fingertips, one hand on either side of the aortic impulse * **_Abdominal Aortic Aneurysm:_** * Focal dilation of abdominal aorta, diameter \> 3 cm

Question 43

**Inguinal Exam**

Answer 43

* Auscultate and palpate the inguinal region bilaterally for the following: * Femoral bruits * Femoral pulses * Inguinal lymph nodes * Inguinal hernias * Ask patient to cough * Inspect and palpate for bulge

Question 44

**Rebound Tenderness** Purpose Technique Positive test Indication

Answer 44

* _Purpose:_ **Peritoneal irritation (peritoneal sign)** * _Technique:_ * Press fingers slowly and gently into the abdomen and then quickly withdraw. Observe! * Ask the patient “Which hurts more, when I press in or let go quickly?” * Maneuver is positive * _Positive test:_ * If quick withdrawal of the fingers produces pain * _Indication:_ * In the RLQ, a positive sign may be suggestive of appendicitis \*If present, then classified as a peritoneal sign, which could be suggestive of intraperitoneal infection, ruptured viscus, etc.

Question 45

**Rovsing Sign** Purpose Technique Positive test Variation of test

Answer 45

* _Purpose:_ **Peritoneal irritation (possible appendicitis)** * _Technique:_ * Press gently and deeply in the LLQ * _Positive test:_ * Referred pain to the RLQ during left sided pressure * _Variation: “Referred Rebound Tenderness”_ * Press gently and deeply in the LLQ and quickly withdrawal your fingers * Pain in the RLQ is a positive referred rebound tenderness

Question 46

**Psoas Sign** Purpose Technique Positive test Rationale for test

Answer 46

* **Peritoneal irritation (possible appendicitis)** * _Technique_ * _With patient supine:_ place your hand just above patient’s right knee and ask patient to raise thigh against hand (resisted straight leg raise) * _With patient lying on left side:_ extend patient’s right leg at the hip * _Positive Sign_ * Increased RLQ pain with either of these maneuvers * _Rationale:_ * Appendix lies closely to iliopsoas muscle. If the appendix is inflamed, any maneuver that contracts or stretches the iliopsoas muscle may cause increased pain in the RLQ

Question 47

**Obturator Sign** Purpose Technique Positive test Rationale for test

Answer 47

* **Peritoneal irritation (possible appendicitis)** * _Technique:_ * With patient supine, flex patient’s right hip and knee and rotate leg internally at the hip * _Positive Sign:_ * Increased RLQ pain * \*May be positive with other etiologies. History is important. * _Rationale:_ * Internal obturator muscle lies closely to the appendix on the right. Stretching the internal obturator muscle in the setting of appendiceal inflammation may cause increased pain in the RLQ

Question 48

**“Shifting Dullness”** Purpose Technique Positive test Indication

Answer 48

* _Testing for:_ * **Ascites** * _Technique:_ * With patient supine, percuss the border of tympany & dullness * Have patient roll onto his/her side, then percuss and mark the borders again * _Positive Sign:_ * An obvious shift in the location of the border * _Indication:_ * Suggests free intra- peritoneal fluid

Question 49

**"Fluid Wave"** Purpose Technique Positive test

Answer 49

* _Purpose:_ * **Ascites** * _Technique:_ * Stabilize mid-abdomen with hand (patient or assistant applies pressure down the midline) * Hold your hand against patient’s flank and tap the patient’s opposite flank with the fingertips of the other hand * _Positive test:_ * If free fluid exists, the examiner will feel a fluid wave strike his/her hand

Question 50

**Murphy Sign** Purpose Technique Positive test Indication

Answer 50

* _Purpose:_ **Gallbladder/ hepatic inflammation** * _Technique:_ * Position fingers of right hand under right costal margin, and apply pressure while having the patient take a deep breath * _Positive test:_ * A sharp halting in inspiratory effort due to pain from palpation of the gallbladder * _Indication:_ * Possibly suggestive of acute cholecystitis

Question 51

**CVA Tenderness** Purpose Technique Positive test Indication

Answer 51

* _Purpose:_ **Kidney inflammation** * _Technique:_ * Place the ball of one hand in the costovertebral angle and gently percuss it with the ulnar surface of your other fist * _Positive test:_ * Pain with first percussion * _Indication:_ * Potentially suggestive of *kidney pathology* (i.e., *pyelonephritis*) or a *musculoskeleta*l cause